’s) wide-ranging coverage of the infection prevention and control world. Everything from interviews with known opinion leaders to the news that infection preventionists and other health care professionals can use on their jobs.

The Duration of Antibiotics: Why Short Is Good in the Long Run

Is it truly beneficial to prescribe longer courses of antibiotics?

Surgical Attire: Policy Development Resources

Human bodies, especially surgical personnel's hair, scalp, and skin, are a major source of bacterial contamination in the surgical environment and a major cause of SSIs. Yet, not it hasn't always been a consideration.

Human Metapneumovirus: What Is it and What Is Being Done About It?

Human Metapneumovirus (HMPV) is not as well-known as its relative, respiratory syncytial virus (RSV), so here is the information that infection control and prevention personnel need to know about this respiratory virus.

Embarking on the Infection Preventionist Role: The Path of an MPH Graduate

The future infection prevention and control pathway is inclusive and invites master of public health graduates and other degrees besides nursing to enter this evolving field.

IPC PROs Helping Each Other: When to Unmask a Long-term Care Facility

In the first of this new series, IPC Pros Helping Each Other: When is the right time to unmask in long-term care? One IP explains how she and her facility unmasked and what led to their decision.

Articles

Take 5 minutes to catch up on Infection Control Today®’s highlights for the week ending June 4, 2023.

Weekly Rounds: Antibiotics Duration, Surgical Attire Policy, and Human Metapneumovirus, and More

According to the Surgical Site Infection Guidelines published in 2017 by the American College of Surgeons and Surgical Infection Society, the most common and costly type of health care–associated infections (HAIs) are surgical site infections (SSIs), accounting for 20% of all HAIs. SSIs occur in an estimated 2% to 5% of patients undergoing inpatient surgery and up to 25% of major surgical procedures.

 Annual incidence of SSIs in the United States is between 160,000 and 300,000, costing from $3.5 billion to $10 billion annually. On average, an SSI increases a patient’s length of stay by 9.7 days, yet approximately half of all SSIs are preventable when evidence-based prevention strategies are implemented.

Infection preventionists (IPs) are vital in supporting the perioperative team by sharing the most current, evidence-based surgical infection prevention strategies to help improve SSI prevention. The operating room (OR) is a challenging environment, with various surgical personnel and medical devices coming together to help improve patients’ lives. Covering surgical services as a novice or even a seasoned IP can be intimidating. In addition to the basic environment of care items, the OR has unique infection prevention challenges. Surgical attire, or OR scrubs (the special surgical clothing required for personnel within the OR suite), is intended to promote cleanliness and reduce microbial contamination in the surgical suite to prevent SSIs.

The human body is a significant source of bacterial contamination in the surgical environment. SSIs have been traced to bacteria from surgical personnel’s hair, scalp, and skin.

 However, maintaining a clean surgical space and reducing microbial contamination wasn’t always a consideration. Through the timeline of surgical attire (

), one can begin to see the development of a better understanding of infection and organism transmission through the changes in clothing.

Surgical attire was initially known as surgical greens because of their color, then were later referred to as scrubs because they’re worn in a scrubbed environment. In 1894, Dr Hunter Robber said, “It is safer and better that all should put on a complete change of costume rather than simply don a sterilized coat and pair of trousers over ordinary clothing.”

 He also suggested that the clothing be made white so they could easily be washed.

When electricity was discovered and electric lights were used in the OR instead of windows and skylights, the combination of bright lights and white attire led to significant glare. “There was a green ghosting effect when shifting gaze from bloody red innards to white backgrounds,” Hunter said.

In 1914, Harry Sherman, MD, FACS, believed that a color scheme might evolve from the red of blood and tissues. He recommended green, a color “less wearisome to the eyes, and [one that] minimized reflection.” He also said green “keeps the surgeon’s eye acute to red and pink.”

 Sky blue became popular for surgical apparel in the 1950s when color television began to be used for videotaping and closed-circuit teaching.

 Today, our surgical scrubs are primarily jade green or misty blue, depending on the vendor’s name given to the color.

Surgical attire has come a long way, but it is—and will probably always be—a hot-button issue due to the variety of organizations and agencies providing input as well as the difficulty of creating and enforcing policies designed for patient and staff safety. The guidance and recommendations are plentiful, which is why it’s vital for IPs covering the OR and the perioperative team to know what the surgical attire policies are as well as the sources used to develop them. Some of the regulatory agencies and professional organizations that have provided recommendations, guidelines, or position statements include the following:

Association of periOperative Registered Nurses (AORN)

Centers for Medicare & Medicaid Services (CMS)

Occupational Health and Safety Administration

Association for Professionals in Infection Control and Epidemiology



To further complicate the surgical attire issue, some states have established their own surgical attire dress code requirements or have adopted a version of AORN or other guidelines. Your local health department may also have further information about state-specific surgical attire requirements, so be sure to contact them as you develop your surgical attire policy.

If your health care facility participates in the CMS programs, you’ll need to follow their surgical attire requirements to be in compliance. They have their own Hospital Infection Control Survey Worksheet that includes a section on surgical procedures with specific surgical attire elements to be assessed by surveyors.6 You’ll need to follow these or risk getting cited. In some instances, they do differ from AORN. Some medical devices and equipment also include manufacturer instructions for use (MIFU) that require wearing specific surgical attire. Check those devices and equipment MIFUs carefully.

Ensure your health care facility’s surgical attire policy complies with the state and local agencies, MIFU, and CMS (if applicable). If none of these are relevant, then the health care facility’s chosen surgical attire, evidence-based guidelines, and consensus statements can be used to develop policies. If your health care facility does not have specific state or local surgical attire requirements, does not have MIFUs that mandate specific surgical attire, is not a CMS participant, and a Joint Commission standard does not explicitly require your facility, then you can choose which evidence-based guidelines or consensus statements to develop your surgical attire policies.

 Surveyors, like The Joint Commission, will survey your specific surgical attire policy. As you know, they don’t make the policy; they confirm that you are following your surgical attire policy.

Most facilities follow AORN’s surgical attire guidelines or incorporate parts of them into their facility-specific surgical attire policies. AORN recently updated the 2015 guidelines on surgical attire in 2019, published in 2020. IPs, including me, have struggled with issues that are addressed in these updated guidelines, including head coverings, arm coverings, beards, shoes, and scrubs outside the surgical suite. What’s not discussed in AORN’s 2020 surgical attire guidelines are patient clothing or linens used in the OR, masks as personal protective equipment, and the use of masks at the sterile field. If you want this information, refer to the AORN Guideline for Sterile Technique

 and the AORN Guideline for Transmission-Based Precautions.

addresses wearing rings, bracelets, watches, nail polish, artificial nails, and other nail treatments.

The rationale for AORN’s 2020 Guideline for Surgical Attire

 includes recommendations for selecting, wearing, and cleaning surgical attire. They are based on the highest-quality evidence available. Recommendations are rated as regulatory requirement, recommendation, conditional recommendation, or no recommendation. These categories are based on the level of evidence, an assessment of the benefits vs harms of implementing specific interventions, and consideration of resources required to implement the interventions

Regulatory requirement: Perioperative team members must implement the recommendation.

Recommendation: Perioperative team members should implement the recommendation unless there is a clear and compelling rationale for an alternative approach.

Conditional recommendation: Perioperative team members may implement the intervention, although the degree of implementation may vary depending on the benefit-harm assessment for the specific setting.

No recommendation: Perioperative team members will need to evaluate whether to implement the practice issue.

AORN states that the guidelines’ recommendations are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the “many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.”

 AORN recognizes that one size does not fit all, and not every organization or professional specialty will use or agree with these guidelines. However, the document does provide evidence-based guidance on surgical attire that can serve as a credible resource to help health care facilities develop perioperative policies and procedures while also considering guidance from professional organizations, state and local agencies, MIFU, and CMS (if applicable).

Development of policies and procedures for surgical attire should be a team sport, ensuring input from all the disciplines (eg surgeons, anesthesia, nursing, infection prevention, environmental services, sterile processing, nurse educator) that contribute to providing quality patient care based on the most up-to-date, evidence-based best practices, with SSI prevention at top of mind.

“Take these pills for 10 days, even if you feel better sooner.” I vividly recall how, in years past, I would impress upon patients the importance of completing an entirely long antibiotic course. My mind’s eye beheld the specter of a half-treated infection raging back in fuller force and powered by newly resistant organisms. Now we know better: The shortest effective course is the way to reduce the risk of patient adverse drug events, antimicrobial resistance, and unnecessary health care costs.

According to the CDC, clinicians prescribed 211 million outpatient antibiotic prescriptions in 2021, which is equivalent to 636 prescriptions for every 1000 individuals, though prescribing rates varied widely by state.

 Once an antibiotic prescription is started, every additional day of use holds the potential for the added risk of adverse events (AEs) for the patient. A study of inpatients with pneumonia

 revealed that antibiotics prescribed at discharge were often excessive in duration, and that each day of excess treatment was linked to a 5% increase in antibiotic-related AEs. Although some AEs, such as anaphylaxis, occur early in a treatment course regardless of intended duration, the risk for AEs, such as hepatotoxicity, nephrotoxicity, and some gastrointestinal effects, changes to the microbiome, and specific drug interactions, can compound over time.

Each additional day of antibiotic exposure also holds the potential to contribute to the emergence of antimicrobial resistance in the patient’s community. More prolonged exposure affords more opportunities for resistance to develop and for natural selection to favor resistant organisms that can then spread to new hosts. Drug-specific pharmacokinetics are also a factor in considering course duration. For example, the elimination half-life for a drug like azithromycin is significantly longer than some other antibiotics so that appropriate courses may be shorter.

New data on the noninferiority of shorter courses emerge yearly for common infections like pneumonia, sinusitis, urinary tract infection, and cellulitis. In 2021, the American College of Physicians

recommended limiting antibiotic durations to 5 days for chronic obstructive pulmonary disease exacerbations and acute uncomplicated bronchitis. They also recommended 5 days for community-acquired pneumonia, considering an extension based on clinical signs.

It takes time for new evidence to translate into practice changes; the lag time between the “lab bench and the bedside” might average 17 years for health care interventions, per one estimate

 or a median duration of 10 days for most conditions studied. Investigators noted that typical durations exceeded those recommended in clinical practice guidelines available at that time, including excessively long courses for sinusitis, community-acquired pneumonia, cellulitis, and cystitis.

Duration of therapy isn’t the only vital component of antibiotic prescribing. The CDC estimates

 that up to half of outpatient antibiotic use is inappropriate in 1 or more ways, including inappropriate duration, dosing, antibiotic choice, as well as unnecessary use of an antibiotic in the first place. In choosing an antibiotic, prescribers are often encouraged to incorporate local antimicrobial resistance and susceptibility patterns into their decision-making. Historically, these data have been hard to find outside the hospital setting. The new Bugs + Drugs feature in the epocrates mobile app offers free geolocalized ambulatory setting antimicrobial susceptibility data on urinary and skin/soft-tissue organisms centered on any zip code in the US.

Indeed, some patients with underlying conditions or other clinical factors may warrant a longer duration of antibiotics. However, long durations—regardless of patient characteristics, infection type, specific antibiotic, and local resistance patterns—are no longer supported by recent evidence. The CDC and major specialty societies concur that the shortest effective antibiotic duration is the one that provides the best outcome for patients and their communities. Reduced AEs translate into reduced unnecessary health care costs. It’s not always the case that a single change in how we practice can benefit individuals and society; this is one of those changes where incentives are well aligned. It’s no wonder that the refrain of “shorter is better” is increasingly inspiring changes to antibiotic prescribing in both inpatient and outpatient settings.

This article is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

Outpatient antibiotic prescriptions — United States, 2020 | antibiotic use | CDC. Published October 24, 2022. Accessed April 14, 2023. https://www.cdc.gov/antibiotic-use/data/report-2021.html

Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. 

. 2019;171(3):153-163. doi:10.7326/M18-3640

Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. 

. 2021;174(6):822-827. doi:10.7326/M20-7355

Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile. 

Measuring outpatient antibiotic prescribing. CDC. Reviewed October 5, 2022. Accessed April 5, 2023. 

https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html

The Duration of Antibiotics:  Why Short Is Good in the Long Run 

Antimicrobial resistance (AMR) is a global public health concern impacting personal and population health levels. Increases in AMR have led to the emergence of multidrug-resistant organisms (MDROs), where once an antibiotic could kill or render the pathogen ineffective, now the antibiotic has little to no impact on the infection’s clinical course. This leads to increased morbidity and mortality in humans, but the full impact is still unknown for the global public health environment.

In 2019, an estimated 2.8 million MDRO-related infections occurred in the United States, resulting in 38,000 deaths.

 Additionally, the annual costs of treating MDRO infections exceed $4.6 billion.

 At the local level, infection preventionists see the impacts of AMR daily. Patients with MDRO infections often have higher acuity with more severe illness, requiring extensive treatment methods and additional resources dedicated by the health care treatment team (eg, personal protective equipment usage, dedicated equipment, and enhanced precautions). They also often result in poorer outcomes. Isolation precautions are one infection control tool to decrease the risk of cross-transmission of MDROs in health care facilities. However, the prevention of the development of additional MDROs in health care facilities frequently falls under the work of the antimicrobial stewardship program (ASP).

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level.

The inappropriate use of antibiotics has long been a public health concern, from the emergence of methicillin-resistant Staphylococcus aureus as a significant health care–associated infection in the 1990s to the current concerns with MDR gram-negative organisms and fungal pathogens (eg, 

). Antimicrobial stewardship efforts are a driving force in preventing the continued practices resulting in the evolution of resistance in these organisms.

Although AMR in microorganisms has developed due to inappropriate clinical use, extensive agricultural use and wastewater runoff have also contributed to the more significant environmental burden.

 One Health is a scientific concept where the interconnections between humans, animals, and the environment all impact community health and well-being.

 From a One Health perspective, the key factors influencing AMR globally are inappropriate antibiotic use in humans and animals, environmental contamination, and poor infection prevention practices.

 One Health focuses on understanding AMR through several methods: surveillance and reporting of AMR, following the epidemiology of MDR pathogens, understanding the impacts on human and animal health, and developing policy and process changes to decrease the risks of AMR.

Animal and agricultural use of antibiotics tends to have a broader use for prophylactic purposes and usage without clinical or therapeutic relevance. Broad-based usage as a preventive for livestock and animal populations has led to misuse and overuse related to increased resistance. In humans, prophylactic use of antibiotics is more limited, which is often due to exposure to communicable diseases or high-risk patients undergoing procedures. However, even with these stricter guidelines, inappropriate use of antibiotics is common in humans.

Other practices that impact the global incidence of MDR pathogens include food production and distribution, international travel (including medical tourism), climate change, and lack of sanitation and environmental hygiene. A more holistic approach can be appreciated as we apply these One Health concepts to local infection prevention and ASP initiatives.

The Joint Commission and other regulatory bodies have developed guidance for various aspects of antimicrobial stewardship activities in health care facilities. In January 2023, The Joint Commission updated the standards to include 12 elements of performance. These elements include ensuring the dedication of resources to ASP efforts, having multidisciplinary involvement in the program, data collection on specified metrics and reporting to the facility leadership, addressing prescribing practices for common clinical indications, and demonstrating implementation of action plans to improve performance.

Similarly, the Centers for Medicare & Medicaid Services (CMS) has included ASP activities in the health care facility Conditions of Participation.

 Additionally, starting in January 2024, reporting of antibiotic use and antibiotic-resistance data will be included in the CMS Promoting Interoperability (formerly titled Meaningful Use) Program for health care facilities.

 A key component of all these requirements is that infection prevention collaborate with ASPs and actively work with stakeholders to perform surveillance reporting, analyze and interpret data, and implement evidence-based practices.

Infection preventionists should be tightly aligned with their facility’s ASP. Inappropriate antibiotic use can take the form of a mismatch of antibiotic to the pathogen, incomplete courses of antibiotics, overuse of antibiotics for colonization or nonbacterial infections, and prolonged courses of antibiotics. ASPs are accountable for addressing these issues and others. Infection prevention and ASP are 2 arms of the same preventive body, impacting patient safety and outcomes. As ASPs evolved in health care, the role of the infection preventionist has not always been well understood, as it often varies based on local levels of support and resources. Some programs have infection preventionists reporting data or statistics on pathogens of interest and MDROs, whereas others may be more intimately involved in developing policy, interventions, education, and strategic plans to advance the ASP agenda.

A standard methodology for ASP and infection prevention programs to work together is diagnostic stewardship initiatives. Diagnostic stewardship includes using microbial diagnostic tests to direct the most appropriate therapeutic interventions. These initiatives ensure patients are diagnosed accurately and are treated with the most appropriate antibiotic for the infection. Examples of diagnostic stewardship initiatives include developing criteria for proper testing of patients for urinary tract infections, bloodstream infections, and 

 infections. Laboratory tests can be optimized to help identify colonization vs active disease, as has been developed for 

 with a 2-step process where an initial highly sensitive test is used first to cast a broad net, followed by a more specific toxin-based test to narrow the diagnostics.

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level. Continued attention by regulatory bodies will help drive the adoption of best practices for ASPs. Similarly, tying reimbursement and financial penalties to reporting efforts highlights health care leaders’ importance in increasing resource allocation and support for ASP activities.

To effectively treat patients who have infections caused by MDROs, the development of new classes and types of antibiotics must be prioritized. Antibiotic development is traditionally not a moneymaker for pharmaceutical companies; therefore, developing new ones is a low priority for drug development. Recently, 230 organizations, health care leaders, public health agencies, and industry representatives have petitioned US Congress to support the Pioneering Antimicrobial Subscriptions To End Up surging Resistance (PASTEUR) Act.

 The PASTEUR Act will incentivize the production of novel antimicrobial agents to offer treatment options for patients and ensure appropriate use requirements, thereby decreasing the risk of escalating AMR.

As the relationship between infection prevention and ASP grows, infection preventionists are key stakeholders in the battle against the rise of MDROs and AMR. The collaboration between the programs is a natural fit, with many parallel goals. The infection preventionist can bring preventive and MDRO mitigation strategies, public health guidance, and biopreparedness formats to the ASP initiatives. Additionally, both programs can look to the One Health concept as an example of how to have a more holistic view of AMR prevention. The environmental impacts of AMR are connected to the community and individual health of patients. The link between facility-level ASP efforts and the more significant global health outcomes can be seen in tactics such as effective surveillance, understanding the epidemiology and emerging MDROs, and diagnostic stewardship. Through these collaborative efforts, the rate of development of AMR and MDROs will decline, and overall patient outcomes and community health will improve.

Antibiotics no longer work against many infections due to MDROs, causing more illness and death. What is antimicrobial resistance (AMR) doing to the environment? 

Exploring the Environmental Impact of Antibiotic Overuse

Proper hand hygiene significantly impacts health care–acquired infections (HAIs), and monitoring completion is essential to improving performance.

Some hospitals invest in electronic monitoring systems (EMSs) to alleviate concerns about traditional in-person observation methods.

 Recognizing the importance of hand hygiene and accurate data to demonstrate actual performance with efforts around quality improvement, Mercy health care system leadership implemented Clean Hands Safe Hands LLC (an EMS headquartered in Atlanta, Georgia) in 2019. The EMS was implemented house-wide in 12 acute care hospitals (> 4000 licensed beds in 26 units), including Missouri, Oklahoma, and Arkansas facilities between 2020 and 2021.

The EMS uses a personalized badging system to identify hand hygiene adherence down to the individual health care provider (HCP) level.

 Each HCP is issued a badge holder/reel with Bluetooth technology to communicate with sensors placed in the alcohol foam and soap dispensers (

). Additional sensors (motion sensors) are placed at the door of all patient care rooms. The EMS correlates a room entry/exit with an HCP badge and interaction with a hand hygiene dispenser (sanitizer or soap) immediately before or after the entry/exit. An audible alert sounds as a reminder if a hand hygiene event is not detected within a defined time. Cloud-based technology gathers all data points, with almost real-time results available through the EMS computer program platform.

There are 2 critical areas where the EMS offered benefits to Mercy: data availability and process improvement. There was a dramatic increase in the overall number of hand hygiene observations completed, allowing observation at all times of the day or night and removing the biases of the in-person observation process. The computer system associated with the EMS was crucial in transitioning those data into useful information. Real-time feedback and adherence trending was available to unit leaders and coworkers by logging into the system. Still, there were also automated emails of results sent to many HCPs, and the data helped fuel healthy competition between individual HCPs or patient care units/departments. Information was available in general adherence reports, as well as advanced graphics that could identify HCPs or certain rooms with higher and lower performance (

One key to improving hand hygiene was the audible alert when a hand hygiene event was not captured, which served as a reminder to the HCP and offered the unexpected benefit of improving the impression of patients about commitment to safety. Upon hearing the reminder, if staff cleaned their hands, they were given credit for proper hand hygiene by the EMS. Based on the results, the increased conversations around hand hygiene from bedside staff to senior leadership further drove process improvement. Workflow optimization and reduction of unnecessary steps necessitating additional hand hygiene were realized. Overall, continual process improvement activities resulted in a 26% increase in hand hygiene performance, from 50% at baseline to 76%, in 1.5 years. Current hand hygiene performance is averaging 84% across the health system.

There were some limitations to using an EMS, and some of them were unexpected. The primary drawback was a higher-than-expected amount of daily work for infection preventionists and other staff charged with maintenance, which is well described elsewhere.

 Continued education was needed to explain how the system worked, which the EMS personnel assisted with via training and resources. HCPs were required to wear a badge to be monitored, and some individuals avoided the system by not wearing their assigned badge. Breakage of the badges, sensors, or sanitizer dispensers was common.

The design of this EMS resulted in inherent “noise” in the system or some incorrect estimation of adherence, which led to initial mistrust of the system. The motion sensors were better at detecting entry/exit of 1 HCP but not as good at detecting groups and busy units, areas with sliding doors and curtains, and small patient rooms. Because of this, workarounds were created to appease the system, including hand hygiene dispenses where the product was not used on the hands. HCPs who strive for perfection are not able to attain that. Overall, there were challenges to belief in results and the ability of the EMS to impact hand hygiene performance, some of which were rectified over time.

Despite some disadvantages, Mercy found value in the EMS, most prominently the organizational efforts to implement and improve performance. Implementing a system was key to understanding that the results from the manual observation process were flawed. The large quantity of data allowed attention to be brought to procedures followed by entire departments that required consultation from infection preventionists to ensure patient safety was maintained.

1. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. 

 2001;47(3):173-180. doi:10.1053/jhin.2000.0882

2. Pittet D, Sax H, Hugonnet S, Harbarth S. Cost implications of successful hand hygiene promotion. 

3. Huis A, Schoonhoven L, Grol R, Donders R, Hulscher M, van Achterberg T. Impact of a team and leaders-directed strategy to improve nurses’ adherence to hand hygiene guidelines: a cluster randomised trial. 

 2013;50(4):464-474. doi:10.1016/j.ijnurstu.2012.08.004

4. Carboneau C, Benge E, Jaco MT, Robinson M. A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. 

. 2010;32(4):61-70. doi:10.1111/j.1945-1474.2009.00074.x

5. Gould D, Lindström H, Purssell E, Wigglesworth N. Electronic hand hygiene monitoring: accuracy, impact on the Hawthorne effect and efficiency. 

.2020;21(4):136-143. doi:10.1177/1757177420907999

6. Limper HM, Slawsky L, Garcia-Houchins S, Mehta S, Hershow RC, Landon E. Assessment of an aggregate-level hand hygiene monitoring technology for measuring hand hygiene performance among healthcare personnel. 

. 2017;38(3):348-352. doi:10.1017/ice.2016.298

7. Using data to improve hospital efficiency and safety. Clean Hands Safe Hands LLC. March 13, 2020. Accessed October 6, 2022. 

https://cleanhands-safehands.com/using-data-to-improve-hospital-efficiency-and-safety/

8. McMullen K, Diesel G, Gibbs E, et al. Implementation of an electronic hand hygiene monitoring system: learnings on how to maximize the investment. 

. 2022;S0196-6553(22)00879-3. doi:10.1016/j.ajic.2022.12.008

Hand hygiene requirements for inpatient health care are numerous and varied. An electronic system to help monitor adherence with some indications benefits the hospital, although it may also introduce some drawbacks.

The Advantages and Disadvantages  of Using a Hand Hygiene Monitoring System

Instrument reprocessing off-site from the facility of use is a concept that has been previously introduced. Many hospital central processing departments (CPDs) sterilize instruments for ambulatory procedural areas under the hospital’s license. Recently, this concept has evolved into off-site sterilization facilities that reprocess instruments for hospitals. Large health care systems often own and operate these facilities and provide service to multiple hospital entities within the system or may be contracted to a third-party off-site sterilization provider. 

Off-site sterilization offers the benefit of additional real estate in the acute care setting. The return on investment (ROI) is realized with the additional hospital capacity for patient beds, procedural areas, and services. For example, some hospital CPDs are located adjacent to the operating rooms (ORs), and relocation of sterilization off site provides the opportunity to expand existing ORs for specialized procedures that require a more significant footprint or add additional ORs. A new hospital building with additional patient beds increases the demand for ORs and other procedural areas. Subsequently, increased volume of reusable medical instruments adds dimension to the proposal for an off-site sterilization plan.

Off-site sterilization offers the benefit of additional real estate in the acute care setting. The return on investment (ROI) is realized with the additional hospital capacity for patient beds, procedural areas, and services.

Real estate conservation is only one aspect of ROI. Consolidation of services also offers the opportunity to decrease labor costs while employing highly trained staff to ensure the product has been properly processed and is safe for patient use. Standardization of instrument sets, processes, and equipment decreases the risk of surgical site infections, resulting in revenue loss in terms of increased length of stay, readmission, and reimbursement from payers.

The planning stage begins with a high-level process map (or value chain map), then core processes and goals are identified. Key stakeholders at this stage include senior leadership, and this mapping may be part of the business plan proposal, which outlines the ROI. Once the decision is made to move forward with off-site sterilization, a more detailed process map defines the decision points based on the input and output of expected steps.¹ Engaging an infection preventionist (IP) who is certified in infection control in this detailed mapping is essential to the project’s quality and success. 

Assessment of needs is critical in the early planning stages with surgeon engagement. This begins with a current inventory and integrity of surgical sets, single instruments, and instrument manufacturer instructions for use (IFUs). The input of these process data will vary from the output, as outdated instruments lacking IFUs or compromised integrity shall be discarded from inventory. Anticipated surgical volume and types of procedures also impact the output data and are inherent to the detailed map. The goal is to standardize instrument sets to ensure capacities for sterilization cycles. Future projections should be incorporated into a designated time frame encompassing the near future. Five years may be a good starting point for this projection, as new procedures and instruments must be anticipated.

Another detail to be explored in this process map is what volume of sterilization services shall remain on-site and for what instruments. Keeping some sterilization and instrument inventory on-site in an emergency or disaster that precludes transport is essential. A “just-in-time” inventory management model may be used for single instruments for scheduled cases that are reprocessed on-site.

Transportation of instruments requires detailed inputs and outputs to identify variables, both anticipated and unanticipated. The Department of Transportation and states Department of Health regulations provide data inputs to the process design. Tracking instrument sets and air quality of temperature and humidity at holding stages adjacent to loading docks and during transport can be managed with electronic documentation. Variances in environmental conditions are unavoidable, as case carts are exposed to outside conditions²with loading dock and vehicle doors opening and closing. The IP can conduct a risk assessment for variances with a time threshold for any parameter that deviates from air quality standards for instrument handling during the transport and case cart holding stages. This assessment should be detailed as output data in the process map and embedded into subsequent policies and procedures.

The detailed process map should also include instrument tracking. This is conducted using an electronic scanning system to scan the instrument to the patient and, through transport, to scan into decontamination, sterilizer, and then to the case cart for transport back to clean storage in the hospital.

Instrument case carts built with the instrument sets and required soft goods for a surgical case may bypass clean storage and be taken directly outside the OR, where contents are unloaded and placed in the OR for the scheduled case per the just-in-time operations model.

Case carts must have a clean identifier on the outside, which is then changed to biohazard identification after the case when soiled instruments are loaded into it. Instruments must be precleaned at the point of use and sprayed with an enzymatic spray or another wetting agent to keep instruments moist until full decontamination occurs at the off-site reprocessing facility. The IP will review the proposed input processes data and make recommendations to the output data as needed to ensure compliance with the CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities³and the Association for the Advancement of Medical Instrumentation (AAMI) standards.

The architectural team draws up the design of the instrument processing facility. The IP reviews these plans to ensure the separation of clean and dirty. Heating, ventilation, and air conditioning should be assessed to comply with the American Society of Heating, Refrigerating, and Air-Conditioning Engineers and CDC requirements of directional airflow from clean to dirty and the associated differential air pressures, temperature, and humidity.⁴ Both decontamination and sterilization should have dedicated anterooms to maintain the differential airflow. Water management is also a critical assessment for the IP to ensure that AAMI standards for critical water and steam are achieved. Additional checks include directional instrument flow process from dirty to clean, including separate loading docks for each and placement of handwashing and eyewash stations. A vendor room for delivering instrument sets is best designed adjacent to the decontamination area with a pass-through chamber that prevents disruption of airflows. A separate clean room for loaner sterile instrument sets should be created the same way adjacent to the sterilization area so that cross-contamination does not occur.

The IP role also expands to employee safety. One example is a selection of personal protective equipment by assessing the ASTM rating of masks and AAMI level for gowns for fluid penetration. In addition, IPs can be instrumental in policy development that references instrument processing guidelines and standards, environmental controls, and employee safety. The expertise of IPs bridges the gap between a rogue process map and evidence-based practices that will withstand regulatory surveys. The assessment skills of IPs apply to selecting a third-party vendor for off-site sterilization, should this option be chosen.

Although the details of a process map and design for off-site sterilization should be narrower to meet the confines of this article, they can easily be further researched by the interested reader.

1. Discover the power of visual process mapping with our comprehensive guide. Creately. Updated December 11, 2022. Accessed March 24, 2023. 

https://creately.com/guides/process-mapping-guide/

2. Parker R, Baumgardner G, Klacik SG. Sterilization-related challenges of off-site transportation of medical equipment. Association for the Advancement of Medical Instrumentation. June 2, 2021. Accessed March 30, 2023. 

https://array.aami.org/content/news/sterilization-related-challenges-off-site-transportation-medical-equipment

3. Appendix B. Air. Guidelines for Environmental Infection Control in Health-Care Facilities (2003). CDC. Reviewed July 22, 2019. Accessed March 23, 2023. 

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html

4. Disinfection and sterilization. CDC. Reviewed May 24, 2019. Accessed March 24, 2023. 

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html

Off-site sterilization frees up hospital space for patient care, improving hospital return on investment. This article explains why and how to go about setting up the service. 

A Road Map to Off-Site Sterilization 

The State of the Infection Prevention Workforce

Infection preventionists (IPs) come from diverse and expanding backgrounds. Their backgrounds and education result in joining the profession with different skill sets. Using the past approach for retaining and developing IPs (who were primarily nurses) will no longer work. Those who have been in the profession longer have recognized and been frustrated by the lack of opportunities for advancement. In a study on retention and professional development, Gilmartin et al

 reported that 34% of respondents listed professional advancement as a reason for separation from their facility.

IPs in current roles are tired. In a 2021 study reported by Rebmann et al,

 the authors concluded that there was extensive burnout among IPs. A 2023 report addressed the well-being of IPs during the COVID-19 pandemic, in which Melnyk et al

 found that sleep guidelines were often unmet, and 65% of respondents reported burnout. Additionally, the many routine infection prevention and control activities put on hold during the COVID-19 pandemic weigh heavy on many IPs. These activities are viewed as essential to a robust infection prevention and control program but could not be maintained during the COVID-19 response.

Nonemergent surgeries were canceled during the COVID-19 response; therefore, no surgical site surveillance existed. COVID-19 interventions included practices that would never have been acceptable during normal times. Practices such as double gloving, repeatedly reusing personal protective equipment (PPE), and wearing unnecessary PPE (eg, bouffant caps and shoe covers) were widespread practices. On another day or time, IPs would have said those actions were never practiced. IPs who entered the field as the pandemic unfolded or at its height have never experienced the ideal infection prevention and control world; they often hit the ground running with little orientation. They will need support to learn daily bread-and-butter infection prevention and control duties.

The COVID-19 pandemic response has highlighted the importance of infection prevention and control and has shined a light on IPs. There is hope for hard-wiring the essential infection prevention and control practices again. However, it will take innovative ways to engage the current IP workforce and train those new to the profession.

Having a baseline for interests, strengths, and opportunities is critical to supporting the development of IPs. Query the team with a formal tool, asking them to identify their strengths, opportunities, and what they want to work on, and have them prioritize these in the event multiple staff members select the same topics. Develop a plan for their professional growth and provide them with the resources they need to be successful. Make the case to the administration that they should attend the national conference even if they still need to have a presentation accepted. The Association for Professionals in Infection Control and Epidemiology (APIC) has a customizable “Convince Your Boss” letter

 to make a case for attending the annual conference. Many APIC educational offerings are remote, with some at no cost to APIC members. Work those topics into IPs’ professional development plans.

Consider ways to retain the dedicated IPs who have worked tirelessly for the past 3-plus years and create models for career advancement by restructuring the roles and job titles to create those pathways. Smathers et al5 described the process used to support organizational growth and retain and recruit experienced IPs. The updated Competency Model

) created by APIC can be used to establish 4 levels: novel, becoming proficient, proficient, and expert. This approach is similar to the nursing ladder models used in many health care organizations, as it recognizes IPs’ current locations and provides a professional path forward if desired.

Developing creative ways to engage semiretired or retired IPs to train the future workforce will also facilitate success. A 2021 report by Gilmartin et al

 found that only 37% of responding facilities assigned a mentor to a new IP. What better way for an experienced IP to give back? They have a wealth of knowledge and experience. The pandemic has taught us that we can do many things with electronic platforms such as Zoom, Microsoft Teams, and Webex. Expanding upon mentoring or buddy programs that were in place before the pandemic is even more critical, as the demand for IPs continues to increase, and those onboarded during the COVID-19 pandemic likely did not receive a full orientation.

Leaders, directors, and managers need to encourage curiosity. Because of an IP’s background diversity, they will be curious about different things. Try to seek out ways to support and/or mentor those curiosities, identify other departments that can help fulfill the curiosity and support the knowledge base, and allow them to spend time in the operating room or sterile processing department to see firsthand the challenges and opportunities present in those departments. IPs need to find their joy and become a subject matter expert in an infection prevention and control topic that intrigues them.

Celebrate big and small accomplishments both within the department and the facility. If an IP masters a new task or has an abstract or manuscript accepted, call that out. When they receive certification or become an APIC fellow, have bagels and coffee. Draw attention to health care–associated infection accomplishments. Facilities will often highlight the recognition they have received from hospital quality rankings, such as The Leapfrog Group or 

, but do not necessarily identify the individual elements contributing to that success. For example, highlighting the 0 central line–associated bloodstream infection rate and underscoring the teamwork between infection prevention and control and the critical care units brings IP recognition. If it was a tough week, celebrate Friday. It is amazing how an ice cream blizzard can uplift spirits. Acts of celebration may seem trivial, but they can contribute to overall well-being.

If the pandemic has taught us nothing else, it has proven that virtual meetings are possible and that working from home for some tasks can be successful. Surveillance is a task that can easily be performed remotely. Determine the feasibility of remote surveillance if it is currently not part of the workflow. Not all team members will want to work from home, but if some do, explore that possibility.

It takes time and effort to develop a competent IP. Stop the IP shuffle,

 or movement between facilities in a region, by helping them find their joy and support their professional growth.

1. Gilmartin H, Smathers S, Reese SM. Infection preventionist retention and professional development strategies: insights from a national survey. 

. 2021;49(7):960-962. doi:10.1016/j.ajic.2021.04.083

2. Rebmann T, Holdsworth JE, Lugo KA, Alvino RT, Gomel A. Impacts of the COVID-19 pandemic on the infection prevention and control filed: findings from focus groups conducted with Association for Professionals in Infection Control & Epidemiology (APIC) members in fall 2021. 

. 2023;S0196-6553(23)00098-6. doi:10.1016/j.ajic.2023.02.013

3. Melnyk BM, Hsieh AP, Mu J, Jopp DA, Miller S. Associations among infection prevention professionals’ mental/physical health, lifestyle behaviors, shift length, race, and workplace wellness support during COVID-19. 

. 2023;51(1):62-69. doi:10.1016/j.ajic.2022.04.004

4. APIC convince your boss letter. Accessed March 25, 2023. https://annual.apic.org/attend/grants-and-scholarships/

5. Smathers SA, Sammons JS. A strategy for expanding infection prevention resources to support organizational growth. 

. 2020;48(9):975-981. doi:10.1016/j.ajic.2020.04.008

6. Billings C, Bernard H, Caffery L, et al. Advancing the profession: an updated future-oriented competency model for professional development in infection prevention and control. 

. 2019;47(6):602-614. doi:10.1016/j.ajic.2019.04.003

8. Gilmartin H, Reese SM, Smathers S. Recruitment and hiring practices in United States infection prevention and control departments: results of a national survey. 

. 2021;49(1):70-74. doi:10.1016/j.ajic.2020.07.024

articles

Infection preventionists come from many different backgrounds. However, many left the field during the COVID-19 pandemic. It will require creative methods to preserve existing IP staff and educate those entering the field.

Retaining and Developing the IPs of Tomorrow: How to Find Meaning as an Infection Preventionist

I was 13 years old when I bought my first encyclopedia of infectious diseases. I was fascinated by the subject. I’m not sure whether my parents were thrilled or concerned by this obsession of mine, but I would carry that book in my backpack and pull it out throughout the day to read in my spare time. Medicine fascinated me, and infectious diseases even more so. Once I graduated high school, I knew beyond a shadow of a doubt that I wanted to be a nurse.

I spent 8 years in the emergency department (ED), first as an emergency medical technician and then as a nurse, before transitioning to the practice of preventing and controlling infections. I theorized that beginning my career as a nurse in the ED was a sensible move; it would give me a good foundation as a nurse before specializing in the field of infectious disease—and it did! After 5 years of nursing in the ED, I began looking for options to specialize in population health and infectious disease. I find it interesting how one becomes an infection preventionist (IP). Infection prevention and control doesn’t yet have a specific educational pathway, so for many of us, it’s something we stumbled upon.

Because May is International Nurses Month, I want to highlight some challenges and joys of being a nurse IP. However, I also have some wonderful infection prevention colleagues with microbiology and public health backgrounds. No matter the background, the complex career of preventing and controlling infections has unique joys and challenges.



I want to wish a very happy International Nurses Month to all my fellow nurse IPs!

One of my favorite quotes comes from Albert Einstein: “It’s not that I am so smart; it’s just that I stay with problems longer.” Einstein reminds us that it is not our intelligence or previous knowledge that most propels us forward in life. Instead, our persistence—despite the challenges that lie before us—leads us to succeed. It is with persistence that I’ve overcome the challenges of being a nurse IP. I could write a book about all the challenges I have faced as a nurse IP. But for today, I’ll mention 2 of the most significant challenges I have stayed with just long enough to overcome them.

Nurses know nothing about epidemiology. Or at least I didn’t, not as a brand-new nurse IP. This was the most significant learning curve in my career. Although I would eventually obtain my master’s degree in public health, I struggledwith the concept of epidemiology in my early days as an IP. We are not taught epidemiological principles in nursing school, and I knew little about incidence rates, prevalence, or how to investigate an outbreak. I probably asked my preceptor to explain the concept of surveillance 3 or 4 times. It was incredibly frustrating. I knew nursing, I knew infectious diseases, but I did not know epidemiology, which is required in infection prevention and control. Luckily, I joined a fantastic team and had an incredible preceptor who, over time, could teach me essential concepts. All this took a lot of time and admitting my limited knowledge of the subject and intentionally working to overcome it. But I stayed with the challenge long enough that I was eventually able to not only apply the principles in practice but to also teach them and create courses through which others could learn and apply those same concepts.


We are not the most loved or celebrated role in health care. While working in the ED, I received many accolades for my role as a nurse. Doctors liked me, and other nurses enjoyed working with me. However, that changed when I became a nurse IP. It turns out that health care workers only sometimes love IPs. After all, we’re the ones coming to them with the unfortunate news of outbreaks, infections, the need for practice change, and constant reminders to wash their hands. It’s understandable that we may sometimes be met with disdain. Our health care colleagues are working hard to provide excellent care to our patients, and it’s discouraging for them to hear that a patient has acquired a health care–associated infection (HAI) or that their unit has an outbreak. It’s stressful news, and we are the deliverers of it. However, it’s equally discouraging for the nurse IP to be met with hostility, disregard, and scorn. As a new nurse IP, I found it challenging to go from being loved in my profession to being disliked. But despite the occasional discomfort, I stayed. I sought to overcome the strained relationships between infection control and frontline health care staff. I developed relationships with the health care teams and fought for their respect. Over time, I’ve regained the appreciation of my health care colleagues. They may not always like what I say, but they respect me and my role.

Despite the challenges, I persist because I see how rewarding this career can be. When we stay in the challenges long enough, we can overcome many of them.

I do not continue in this career for the challenges it has brought. I stay for the many joyous moments I’ve experienced. I love my job; I get so much joy from our work of preventing and controlling the spread of infectious diseases. It’s fascinating, enthralling, and exciting for many reasons.

We save lives. Sometimes I wonder how many lives I’ve saved as a nurse IP. We calculate this occasionally to show the health care community the tremendous value of improving the prevention and control of infections. We’re preventing morbidity and mortality in health care through targeted interventions designed to prevent the acquisition and spread of infection. And quite simply, I find that incredible. It underscores why I continue to persist in this career, despite its challenges. I take great pride and joy in the fact that my infection prevention colleagues and I are decreasing the health care cost, preventable illness, and death in health care facilities. It’s beyond exciting to watch the decreasing trend of infections after working long and hard to determine potential reasons for a high infection rate, then applying interventions to decrease those infections successfully. Someone out there is alive because an IP investigated, discovered, and applied practice changes to reduce infections in a specific area of medicine. And that, my IP friends, is something to be celebrated.

We are the Sherlock Holmes of health care. I’ve always loved a good mystery. As a nurse IP, we can act as detectives of health care. We are, in a sense, solving crimes by working to determine which organism, practice, product, or knowledge gap has led to the spread of HAIs. This is captivating, exciting, and tremendously fun. If you’re a nurse trying to determine whether infection prevention is a career you’d like to pursue, ask yourself whether you enjoy a good mystery. If you do, then you’re likely to enjoy the career of preventing and controlling infections. We’re constantly solving the mystery of rising infection rates and intervening to prevent the next “crime.”

Being a nurse IP is not for the faint of heart. I thought my job as a nurse in the ED was challenging, and many times, it was. However, my career as a nurse IP has also come with its trials. But despite the challenges, I love the satisfaction I get from helping improve the care of our patients through the prevention and control of infections. I’ve seen the downward trending graphs of infection cases indicating the lives we’ve saved, and I have loved the thrill of solving the mysteries left behind by the microscopic organisms wreaking havoc on our health care communities. A nurse IP may not be the easiest role in the health care community, but it is among the most rewarding.

I want to wish a very happy International Nurses Month to all my fellow nurse IPs! May you persist through the challenges of this career and enjoy all the ups and downs of this most rewarding profession.

No matter the background, the complex career of preventing and controlling infections has unique joys and challenges.


The Challenges and Joys of a Nurse Infection Preventionist

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal, and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate health care personnel and start a dialogue about microbiology-related imperatives.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. 

Infection Control Today, May 2023, (Vol. 27, No. 4)